| NPI | 1962140434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11019813) |
| Additional Taxonomies | 106S00000X Behavior Technician (Licence: FL RBT-20-123140) |
| Enumeration Date | 2022-05-25 |
| Last Update Date | 2025-01-06 |